soh nomination form 2013

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					                        ‘Spirit of Humanity Awards’ 2013




                                                           2013
BACKGROUND
AmeriCares India is a nonprofit organization providing humanitarian medical aid on a regular basis and responding
immediately in disaster situations. Currently AmeriCares India works with international and local charitable organizations
including governmental and non governmental agencies, hospitals to assess humanitarian needs of health and respond to
those that are most critical, across 26 states involving our network of 120 affiliate partners across India.

‘AmeriCares India Spirit of Humanity Awards’ was established in 2010 as India’s first healthcare awards to honor and
recognize individuals or organizations that have made outstanding contributions towards improving healthcare and creating
a healthier & stronger society.

The objective of the awards is to provide a platform and award unprecedented and exemplary work in the field through
rigorous search, nomination and selection of people or organizations by using a transparent process, an independent jury
and third party oversight.

NOMINATION CRITERIA
Nominees: Organizations & Individuals can nominate themselves or others.

Nominees must be:

a. Indian Citizens above the age of 18yrs or

b. Registered organizations that have been in operation for a minimum of 3 years in India: Non-governmental, charitable or
nonprofit entities, government or private hospitals, private companies, government agencies, universities and multilateral
organizations are eligible for consideration.

c. Individuals or organizations who have won the award would not be eligible to reapply for 3 years in the same category for
which they won the award. However they could apply in a different category.

Registration documents are required for nonprofit institutions and must be mailed along with the Nomination Form. All
necessary documents are listed below.

Organizations registered with GuideStar India may submit their GSN (GuideStar Number)

Contact with any jurors by a nominee or by somebody on behalf of the nominee will be grounds for automatic
disqualification.
TIME LINE

      1.                        Nomination Open
              ( Online submission is encouraged ; hardcopies plus                       October 2, 2012
                 softcopies in CDs are also accepted by courier)
      2.              Deadline for accepting nominations:                               November 30, 2012
      3.                 Screening Committee Meeting                                    February 2013
      4.                      Intimation to finalists                                   February 2013
      5.         Oral Presentation by finaliststo Jury in Mumbai                         April 6, 2013
      6.                  Award Ceremony at Mumbai                                       April 6, 2013

 CATEGORIES
 Awards will be given out in various categories like:
 I.   Child Nutrition
 II.  Women's Health
 III. Infections
 VI.   Oncology – Service
 V.   Oncology – Research
 VI.  Neurology/ Mental Health
 VII. Jury's Choice Award - for those who do not fall into the above categories

 Based on additional support, we may add more categories.

 AWARDS
 A) For the winner:
 1.     Donation of Rs. 1 lakh to your charity or a charity of your choice
 2.     Trophy
 3.     Certificate of Excellence signed by the international jury.

 B) For other finalists:
 All finalists shall receive a Certificate of Honor signed by the international jury.
 (Please check our website for regular updates)



ASSESSMENT GUIDELINES
Individuals/organizations will be evaluated on the basis of their work done in the last 5 years (highlight
accomplishments in the period of 2007-2012. Contributions can be in any or multiple aspects of healthcare – e.g.
education, treatment, prevention, research, capacity building, advocacy, processes, inventions, methods, guidelines,
etc. Nominees will be assessed on the following parameters (as many as applicable for each nominee):
   1. Vision & Mission
   2. Objectives of the Organization/ Individual
   3. Working in which area/s in India
   4. Details of work/ programs of the last 5 years ( Annual)
   5. Populations or individuals served, and how they benefited
   6. Measurable outcome and benefits
   7. Leadership qualities/ Role models to others
   8. Use of innovative and creative approaches
   9. Ability to scale up and adaptability across geographic and organizational boundaries
   10. Organizational capacity (including financial and programmatic stability) / Number of Staff ( full time part
        time & volunteers)
   11. Details of Past budget ( last 3 yrs)
   12. Collaboration with other organizations / Individuals
   13. Recognition/ Achievement
   14. Confirmation by Referees
   15. Applications should include a brief (500 words max) describing their contribution in respect to the specific
        category in you like to nominate yourself.


DOCUMENTATION REQUIRED

The following documents are required for nominations:
   1. Completed word document of the nomination form
                                                AND
   2. PowerPoint presentation with salient points in the format provided.
   3. Registration Certificate
   4. Registration certificate under Section 12 A
   5. Audited Accounts of last 3 years
   6. Acknowledgement of Income Tax return along with IT return filed (last 3 years)
   7. FCRA certificate (if any) and latest copy of FCRA return FC-3
   8. Pan Card Xerox
   9. Annual Reports of the last 3 years
   10. Applications should include a brief description of how the nominee has made a sustained contribution in the
        respective Award category
   11. NGOs registered with GuideStar India can skip item 3 & 8, upload 4,5,7 and send the rest.

Evaluation Process:

   1.   Screening of all completed nominations received by the deadline will be performed by a core committee consisting
        of healthcare professionals from various specialties as well as experts from other fields.

   2.   Shortlisted nominations will be required to come personally and make a presentation on the day of the event to an
        international Jury consisting of health professionals & eminent people from different sections of the society.

   3.   A winner will be selected by the Jury from the presentations made for in each Award Category.

   4.   The entire processes will be done with the help of volunteers and certified by KPMG (Knowledge Partner)
FORM SUBMISSION

The Nomination Form and the PowerPoint presentation along with all documentation, CV (if applicable), supporting
documents, and the narrative (if any) must be received by us no later than Friday November 30, 2012.

The preferred mode of application is online. All supporting documents should be scanned and uploaded. An
acknowledgement will be sent only to nominees whose completed application is received.

Completed Nomination Forms and PowerPoint presentation (hard copy along with the copy on CD) could also be sent to

By Courier       : AmeriCares India Foundation, Seagull House, 1st floor, P.No. 6, Shivaji Colony, Chakala, Andheri
Kurla Road, Andheri East, Mumbai 400099
Website          :       www.americaresindia.org
To fill the form online: www.spiritofhumanity.net
Please contact Aiswarya Vijayadharan at Tel. No.: 022 6556 8098 for more details or any clarifications email at
spiritofhumanity@americares.org
                                                    BASIC INFORMATION
 Name of the nominee
 Organization / Individual - as per valid legal
 document)
 Is the nominee an individual or a organization
                                                         Individual          Organization
 (please tick one option)
 Is the nominee individual a citizen of India &
 above 18 years of age at the time of filing this        Yes                  No
 nomination? (Applicable for Individuals only)

                                                             Guidestar India. If yes, pls write GSN: ________
 Is the nominee registered with any of the
                                                             GiveIndia. If yes, pls write reference #: ________
 following organizations (Tick if yes and write the
                                                              Samhita . If yes, pls write reference #: ________
 reference number (if any))
                                                             Indian Ngos. If yes, pls write reference #: ________
                                                             Other:________________.
                                                              If yes, pls write reference#: _____________


                                                         Yes                  No
 Is the nominee organization registered in India
                                                      Registration No. ___________________
 Date of Incorporation/Registration
                                                        Date :          Month :               Year :
 (organizations) or Date of Birth (individuals)

 For which of the following Award Category is           Child Nutrition          Neurology/ Mental Health
 this nomination being filed?                           Infections                Women's Health
                                                        Oncology -Service        Oncology Research
 (Please tick ONLY ONE category
                                                        Jury's Choice Award-for those who do not fall into the above categories

 Registered Address (Complete Address : as can        _________________________________________________
 be supported with valid legal document)              _________________________________________________
                                                      _________________________________________________

 Mailing Address ( Applicable if different from       _________________________________________________
 the above)                                           _________________________________________________
                                                      _________________________________________________
                                           PERSONAL INFORMATION
                                                              Mr.    Ms.         Mrs.      Dr.
Name & Salutation of the nominee
                                                      First Name   :
(For Organization : Mention name of a person from
                                                      Middle Name :
the organization who is authorized to represent it
                                                      Last Name   :

Email Id: __________________________________          Cell Phone No: _ _ _ _ _ _ _ _ _ _ _ _


Landline No: STD Code :            No:                Fax No ( If Available) _________________



NOMINEE’S WORK

Please describe the nominee’s work till date (in the appropriate Award category) & a record of all achievements made
over the last 5 years (2007– 2012). For fields that are not applicable, please leave blank or write not applicable. (Add
pages if required)
    1. Vision & Mission




    2. Objectives of the Organization / Individual ( Add pages if required)




    3. Working in which area/s in India ( Add pages if required)




    4. Details of work/ programs of the last 5 years ( Annual) ( Add pages if required)




    5. Populations or individuals served, and how they benefited ( Add pages if required)




    6. Measurable outcome and benefits ( Add pages if required)
7. Leadership qualities/ Role models to others ( Add pages if required)




8. Use of innovative and creative approaches ( Add pages if required)




9. Ability to scale up and adaptability across geographic and organizational boundaries          ( Add pages if
    required)




10. Organizational capacity (including financial and programmatic stability) / Number of Staff ( full time
    part time & volunteers)




11. Details of Past budget ( last 3 yrs)


  Financial Years        Total Income (Rs in Lakhs)           Total Expenditure (Rs. in Lakhs)

  2011 - 2012

  2010-2011

  2009 - 2010



12. Collaboration with other organizations / Individuals ( Add pages if required)




13. Recognition/ Achievement ( Add pages if required)
14. Applications should include a brief (500 words max) describing their contribution in respect to the
   specific category in you like to nominate yourself.
15. REFERENCES


Please provide two individuals who can serve as additional references for the Nominee.

Reference 1

Name




Address                  State :                            Pin Code :

                         Telephone :                        Email Add :



Reference 2

Name




Address                  State :                            Pin Code :

                         Telephone :                        Email Add :




  LIST OF SUPPORTING DOCUMENTS/ OTHER DOCUMENTS ENCLOSED (INCLUDING CV
                       AND NARRATIVE IF APPLICABLE)
UNDERTAKING BY THE APPLICANT/ NOMINEE
1.     All statements mentioned in the Nomination Form & the narratives (if any) are true to the best of our knowledge &
       ability.
2.     If shortlisted for an Award, the nominee shall be available on 6th April 2013 to make the presentation to the Jury and
       also at the Award ceremony in Mumbai. In case the nominee is not able to attend the ceremony, the Award shall be
       given to the ‘alternate’ Awardee selected by the Jury for that Award category.
3.     We will accept the Jury’s decision to be final & binding.
4.     We give permission to AmeriCares India Foundation to use the nominee’s name, photograph, etc. in any promotional
       material that they want to develop.
5.     The references are not related to me/ us.
6.     We authorise AmeriCares India Foundation to share our documents and contact details with GuideStar India to
       facilitate our registration.
7.     We are aware that the Jury may decide not to select anyone in any Award category if the nominations are not of
       sufficiently high standards.
8.     We give our consent to AmeriCares India Foundation & their representatives to do the due diligence & verify all
       accuracy of the information provided in the application.
9.     We will not attempt to influence the selection process or contact any jury member. Also we are aware that any such
       attempt shall automatically disqualify this application.




        Signed on ___ date of _______ 2012.                    Signed on ___ date of ________ 2012




        Name & Signature of Applicant                          Name & Signature of Nominee

                                                               (if different from Applicant)



FOR OFFICE USE ONLY



Nomination No:           /                             Date Form Received:     /

Date Referee 1 Comments Received        /              Date Referee 2 Comments Received        /

Completeness Verified: Yes / No                        No of Supporting Documents Recd

Date of Birth/ Registration Proof Appropriate          Yes / No

Comments:                                              Category Assigned:
Name:   Signature:

				
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